Allowing clinicians to add laboratory testing to previously collected specimens is a high-frequency task in many clinical laboratories. The process allows clinicians to assess current lab values and request further testing on existing samples, thereby leading to more rapid test turnaround and potentially, improved patient care—the process reduces the number of blood draws and other specimen collections a patient must endure. Geisinger Medical Laboratories (GML) strongly endorses the add-on testing process to optimize the benefits associated with efficient use of patient samples already in the laboratory.
GML oversees laboratory services at 7 hospitals and more than 100 clinics and regional laboratories throughout northeastern and central Pennsylvania. The Geisinger Health System continues to expand and the laboratory service line strives to lead in standardization and efficiency of services.
Why Pursue Change?
Previously, requests for add-on laboratory testing followed the standard inpatient and emergency department (ED) laboratory test process. Add-on orders were placed via the electronic health record (EHR), which interfaced to the laboratory information system (LIS) triggering a need for specimen collection. Multiple steps in this process contributed to errors associated with missed, delayed, or incorrect add-on tests:
• GML’s original add-on workflow required clinical staff to contact the Laboratory Contact Center via telephone call or instant message. This communication served as the mechanism for the laboratory to act on the request, but communication failures occurred.
• Add-on tests need to be associated with the proper laboratory specimen and collect date/time, but the interfaced orders could not be automatically associated with the appropriate LIS specimen, and manual intervention was necessary. The original add-on process required the laboratory to cancel the interfaced order and reorder the test, coupling it with the proper specimen. This cancel and reorder process was inefficient, increased the potential for record ambiguity, and contributed to clinician dissatisfaction and confusion. Clinicians assumed the laboratory was simply canceling many of their order requests.
• When add-on tests directly interfaced to the LIS, this workflow temporarily signaled the need for a specimen collection (even though the test was for an existing specimen) resulting in unnecessary specimen recollects.
• The inpatient and ED add-on test process differed significantly from the outpatient process, complicating decision steps for both clinician and laboratory staff.
Evaluating Process Options
To address the issues with the add-on test request process, a multidisciplinary team was created comprising content experts in LIS, laboratory operations, quality, customer support, EHR, and IT interface. This team mapped the existing inpatient add-on process from laboratory test order to result, revealing an overly complicated workflow. The map also indicated significant process variations between GML lab sites once an add-on test notification was received.
The team chose to break the improvement initiative into phases in order to narrow the scope and effectively focus on each piece of the overall workflow. An ad hoc team was assembled to concentrate on the test relay process, beginning with the electronic order and ending with the receipt of the add-on test in the testing lab.
The team collaborated with laboratories outside of GML to obtain new ideas and evaluate potential options. Each possibility was diagramed with the choices eventually narrowed to two viable options—the use of existing test codes in conjunction with an EHR “frequency” of add-on, or the use of a new generic add-on test where the clinician would enter test additions via free text. A listing of pros and cons for both options was generated. The resources required for each process step were forecasted, as were the possible upstream and downstream impacts of each option. The add-on “frequency” workflow was chosen after mindful assessment by the team. This option utilizes existing EHR test codes, allows clinicians continued use of EHR order sets, and reduces the risk of test ambiguity between the EHR and LIS. It did not require laboratory interpretation of free-text test requests, nor did it create an extra generic test order in the EHR and LIS.
An implementation plan was initiated for the new workflow that required several build changes within the EHR, as well as alterations to the LIS interface. Overall, the plan required significant practice changes for laboratory staff, physicians, and nurses, therefore a comprehensive education plan was devised to improve the likelihood of a successful launch. As several efficiencies were anticipated as a result of the new add-on workflow, detailed data collection was established to measure the effect of the changed process.
Discussion and Conclusions
A number of efficiencies and goals were realized as a result of the revised laboratory test add-on process:
• 30% decrease in overall telephone call volumes to the Laboratory Contact Center
• 90% decrease in manual documentation related to add-on request events
• 6,000 canceled laboratory test records eliminated in the EHR and LIS, monthly
• Improved add-on process reliability
• 19% increase in add-on test orders
Several lessons were learned and a few new challenges surfaced over the course of this project:
• The laboratory realized post-implementation that some laboratory tests should not be ordered as add-on tests (eg, blood cultures, blood gas panels). The EHR was
adjusted to help prevent these add-on requests.
• Clinicians favored the new process for clinical pathology tests and requested the same for anatomic pathology testing.
• Under the former process, add-on test requests were often batched. There was one communication to the laboratory for multiple add-on tests for one patient. The revised process is electronic with no batching of notifications. Laboratory sites without robotic/automated specimen retrieval are challenged to locate samples manually and repeatedly.
• Add-on orders are placed by clinicians without an assessment of available specimens or viability. This leads to inquiries with clinicians on how to proceed if add-on requests cannot be fulfilled.
• One-on-one clinician and staff training related to process change was found to be more effective than traditional email and message education. Laboratory sites that pursued in-person training opportunities with nursing and physicians to explain the process and expected outcomes had a smoother transition.
The revised laboratory add-on process was a favorable approach for Geisinger Medical Laboratories. The new process, as supported by quality data, makes better use of EHR functionality and staff resources, with improved process reliability. Non-value steps in the add-on process were reduced and the change standardized the outpatient and inpatient add-on workflows and removed several pre-laboratory pain points that contributed to missed testing and testing delays.
Barbara Booth, BS, MT(ASCP), is the Laboratory Quality Systems Coordinator at Geisinger Wyoming Valley Medical Center in Wilkes Barre, Pennsylvania. She provides leadership in coordination of regulatory and process management activities. Barbara earned her degree in Medical Technology from Bloomsburg University of Pennsylvania, is certified in Just Culture, and is a volunteer inspector for the College of American Pathologists.
Jamie Serafin, BS, MT(ASCP), is the Team Leader of Geisinger Medical Laboratories’ Contact Center located in Danville, Pennsylvania. She leads a 24/7 customer experience operation servicing seven hospitals and numerous outpatient clinics. Jamie earned her degree in Medical Technology from Bloomsburg University of Pennsylvania.
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